A question for our medical field members

Ed1937

Three years ago my wife had problems with AFIB. It seems to have resolved itself now. She also had indications in an MRI that she had suffered TIAs in the past, which she was unaware of.

When Covid hit hard about a year ago, I asked our doctor if my wife could go off coumadin, and take aspirin instead so I wouldn't have to take her out for testing, where contracting Covid would be much more likely. He wanted us to stay in the house, but to reduce coumadin from 1/2 pill four times a day, and a full pill three times a day to 1/2 pill daily. He felt that would be better than aspirin. That's what we have been doing for the last year. No testing.

Now we have been vaccinated, so risk is minimal for contracting Covid. But during the last year, my wife has become much, much harder to take anywhere, and if she goes back to the original dose of coumadin, she will have to get tested at least monthly, and likely every two weeks until the right dose is found again. People here understand how hard it is to take someone with dementia anywhere, so I'm asking if it was you, and your LO was so hard to take anywhere, would you stick with 1/2 pill daily, or would you put up the good fight to take her for testing? I am not asking for medical advice. I am asking what you would do.

Crushed

1) is your "doctor"  a  cardiologist? If not you need one. 

2) What is your plan if she has a heart attack?   DW  is a DNR  I have made that decision after careful discussion with my children.    Those decisions drive the medication decisions.

3) finally, IMHO   never think about medication in terms of "pills"  e.g. "1/2 a pill" 

 PILLS COME IN MG  

 Warfarin (coumadin ) comes in 1 to 10 mg  tablets. What dose is she on?

  If the patient’s CYP2C9 and VKORC1 genotypes are not known, the initial dose of COUMADIN is usually 2 to 5 mg once daily. Determine each patient’s dosing needs by close monitoring of the INR response and consideration of the indication being treated. Typical maintenance doses are 2 to 10 mg once daily.

How often do they do INR (clotting ) They can draw blood at home

https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=167&contentid=international_normalized_ratio

there is even in home testing 

https://natfonline.org/2020/08/inr-testing-at-home/

I taught FDA medical device regulation. 

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Ed1937

Thank you both for the replies. Yes, she has a cardiologist. 5mg pills, so 2 1/2mg four times a week, and 5mg three times. The links help too.

I'll have to check to see if they do home visits for the lab results. I learn something new every time I make a new thread.

shardy

I'm not in the medical field but thought I'd drop in..

 Have had many family members on Coumadin, I think 6,  never prescribed for more than once a day.

 Always had to have protimes done each week..

took Jim ,who was on it for afib, and switched to aspirin, and then lowered to baby aspirin. No problem. And no recurring afib. He is now over 1 year on just the baby aspirin..

What I would do is go to a cardiologist and ask those exact questions. Good luck.

Ed1937

shardy wrote:

What I would do is go to a cardiologist and ask those exact questions. 

I think that's what we'll do. Revisit the question. She hasn't seen him for a while, and probably should just to be safe. Thanks.

 

Marta

The half life of warfarin is 20-60 hours, so once a day dosing is possible. I have never prescribed it for more than once daily, usually given in the evening to allow for blood test results and dosage changes to be communicated to the patient.  

I think you meant that your wife alternated the dosages four days per WEEK with three days per WEEK. 

M1

Ed if she's been stable doing what you're doing for the past year, I'd just stick with it and keep doing it and forget about testing unless something else happens--needing antibiotics, for instance, can throw Coumadin doses way off (usually requires taking less Coumadin).  Balancing anticoagulation in older folks is always hard--and especially with dementia added in.  It's always stroke risk vs. bleeding risk.  If your wife is at all unsteady on her feet, the risk for dangerous bleeds with falls goes way up.   From what you've described of her condition, I certainly wouldn't put her through monthly testing.

The drugs you could consider switching to are called factor X inhibitors--Eliquis and Xarelto being common ones.  They do not require testing, but whether or not to use them in A. fib depends on the underlying cause of the A. Fib--if she has a heart valve problem (like mitral regurgitation for instance), these newer drugs are not as effective as coumadin in preventing stroke.  But again, you're balancing a lot of different things here, and it would be an option to discuss.  In the interest of simplicity though, I'd vote for if it ain't broke, don't fix it.....

Ed1937

Marta wrote: 

I think you meant that your wife alternated the dosages four days per WEEK with three days per WEEK. 

Right. I can't believe I wrote that! Maybe I can blame it on Google.

Ed1937

M1, thank you. Your perspective is appreciated.

Gig Harbor

My husband switched to eliquis from Coumadin. The downside is the cost. Once he starts falling I will talk to his cardiologist about stopping it. A head bleed from a fall vs a stroke will be the choices we face.

JDancer

Something else to think about with coumadin-as if life is not complicated enough-is diet. Vitamin K negates coumadin, so blood levels change with the amount of vit k consumed in things like dark, leafy vegetables. Some of our LO have "unusual" eating habits, so this may be a consideration.

Your question can also be viewed through a wider lens. My approach to my husbands health care has evolved with his disease. Unnecessary procedures and treatments have been discontinued. What's unnecessary? I consider pain, risks, expense, difficulty and overall results when making decisions. These decisions are difficult, but I believe we must each come to our own conclusions. No judgement.

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JDancer

Ed, you said your LO's A Fib has resolved. If so, does she need to be on a blood thinner? A Fib can come and go. If they tolerate it, wearing a (Holter) heart monitor would let you know if she still has to worry about a Fib and the blood clots it can cause.

Ed1937

Thank you, friends. I know AFIB can come and go because that happened with her.  She hasn't seen the doctor for a while, and it might be time to make another appointment. I'd like to get her off whatever meds we can, but don't want to be too risky doing it. I think a heart monitor would probably by out of the question for her, but if the doc ordered one, we might give it a shot.